Fillable January 2016 Pursuant to Drinking Water Protection Regulation (Island Health)

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January 2016 Pursuant to Drinking Water Protection Regulation (Island Health)

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Country of origin: CANADA
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January 2016
Page 1 of 2
CONSTRUCTION PERMIT WAIVER REQUEST FORM
Pursuant to Drinking Water Protection Regulation - Section 6(3) (C)
Applicant: _______________________________________________________ Population Served: ____________
Legal Owner: ___________________________________________________ Number of Connections: ________
Water System Name or Business Name: __________________________________________________________
SECTION A
Is this a New System? Yes ______ (If No, proceed to Section B)
NOTE: For this request, ‘new’ includes any system without a valid operating permit, including currently
operating unapproved systems. Generally, a system is considered new only if an operating permit has never been
required (i.e. new construction, systems previously serving a single-family home.)
If Yes, submit the following:
Application for Drinking Water System
Site plan showing water source(s), buildings, potential sources of contamination (septic systems, chemical
storage, fuel storage, etc)
Schematic of proposed construction
Equipment manufacturer’s information and certification
Water test results - both chemical and bacteriological
Water source and current treatment information (SECTION C)
For groundwater, well log, well plate number, pump test, contact info for well driller/ pump installer
For surface water, a copy of the water license, details of intake
SECTION B
Is this an Existing system? Yes ____ (If No, return to Section A or contact the Drinking Water Officer (DWO))
NOTE: Existing systems are only those with a valid operating permit issued to the current owner.
If Yes, provide the following details:
A schematic or explanation of the proposed construction
Equipment manufacturer’s information and certification
Water source and current treatment information (SECTION C)
For a NEW water source, submit water test results (chemical and bacteriological)
NOTE: A source may be NEW if it is not indicated on the operating permit- if in doubt, discuss with the DWO.
SECTION C
Water Source Information:
Deep well Shallow well Flowing surface water Non-flowing surface water Spring Ocean
Infiltration gallery Roof top harvest Hauled water: (hauler: ) Bulk Water (system: )
Existing Disinfection:
None chlorination chloramination ultraviolet irradiation ozone other:
ExistingTreatment: NSF approved Yes No
Rapid Sand Filtration
Carbon Filtration
Desalination
Distillation
Slow Sand Filtration
Cartridge/Bag Filtration
Flocculation
Zeolite sand
Electrodialysis Reversal
Diatomaceous Earth
Sedimentation
Pressure Filtration
Membrane Filtration (MF, UF, or NF)
Reverse Osmosis
None
Ion Exchange (Fe/Mg removal, softening, etc)
Other:
Construction Permit Waiver Request Form Page 2 of 2
Water System Name: ______________________________________________________________________
Brief Description of Proposed Construction: ___________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
I hereby request a construction permit waiver
Owners Name: ___________________________________ Signature: ________________________________
Contact Phone Number: ________________________________ Submission Date: ______________________
Mailing Address: ___________________________________________________________________________
OFFICE USE ONLY:
Waiver recommended by Drinking Water Officer: Yes No
Comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________ ___________________________
DWO Signature Date
Public Health Engineer Decision
Waiver Granted: No Yes - Applicant to notify DWO upon completion of works.
Comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________ ___________________________
PHE Signature Date
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January 2016 Pursuant to Drinking Water Protection Regulation (Island Health)

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Completed 25 November 2020

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